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NPI Code Detail

MEDICARE: EVELYN CO LICENSE MARRIAGE AND FAMILY THERAPIST INC

MEDICARE: EVELYN CO LICENSE MARRIAGE AND FAMILY THERAPIST INC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106H00000XMarriage & Family Therapist
2261QM0850XAdult Mental Health Clinic/Center
3261QM0855XAdolescent and Children Mental Health Clinic/Center
4101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1730940115
Entity Type Code : Organization
Provider Name (Legal Business Name) : EVELYN CO LICENSE MARRIAGE AND FAMILY THERAPIST INC
Provider Business Mailing Address
First Line : 15714 HALLDALE AVE APT B
Second Line :
City : GARDENA
State : CA
Zip : 90247-3842
Country : US
Telephone Number : 800-803-4584
Fax Number : 800-803-4584
Provider Business Practice Location Address
First Line : 13323 W WASHINGTON BLVD STE 200
Second Line :
City : LOS ANGELES
State : CA
Zip : 90066-5163
Country : US
Telephone Number : 800-803-4584
Fax Number : 800-803-4584
Authorized Official
Title or Position : CEO
Name : MS. EVELYN CO
Credential : LMFT
Telephone Number : 323-803-3131
Provider Enumeration Date : 01/22/2024
Last Update Date : 01/30/2024

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